From the Guidelines
Patients presenting with urinary pain, gross hematuria, followed by microscopic hematuria with significant leukocyturia, and a negative nitrite test are likely suffering from a urinary tract infection (UTI) [ 1 ].
Treatment Plan
A treatment plan should include:
- A 7-day course of trimethoprim-sulfamethoxazole (160mg/800mg orally twice daily) or ciprofloxacin (250mg orally twice daily) for uncomplicated UTI [ 1 ]
- Phenazopyridine (200mg orally three times daily) for up to 2 days to alleviate urinary pain [ 1 ]
- A urine culture should be obtained to guide further antibiotic therapy if necessary [ 1 ]
- Follow-up urinalysis should be performed 1-2 weeks after completion of treatment to ensure resolution of hematuria and leukocytes [ 1 ]
Additional Evaluation
Given the initial presentation of gross hematuria, which has a high association with malignancy [ 1 ], further evaluation, including cystoscopy and imaging, may be warranted to rule out underlying cancer or other significant conditions [ 1 ].
Risk Factors
Practitioners should be aware of risk factors for cancer, such as age, smoking, and occupational exposure to chemicals, when considering the finding of hematuria [ 1 ].
Follow-up
If the initial evaluation is negative, consideration should be given to repeating urinalysis, voided urine cytology, and blood pressure determination at regular intervals to monitor for the development of significant urologic disease [ 1 ].
From the Research
Patient Presentation
The patient presents with dysuria, gross hematuria progressing to microscopic hematuria, and significant leukocyturia, with a negative nitrite test.
Diagnostic Considerations
- The presence of dysuria, gross hematuria, and significant leukocyturia suggests a possible urinary tract infection (UTI) 2.
- A negative nitrite test does not rule out a UTI, especially in patients with a high pretest probability of infection based on symptoms 2.
- Microscopic urinalysis is comparable to dipstick urinalysis as a screening test, and bacteriuria is more specific and sensitive than pyuria for detecting UTI 2.
Treatment Plan
- First-line treatments for UTI include nitrofurantoin, fosfomycin, and trimethoprim-sulfamethoxazole (when resistance levels are <20%) 2.
- The choice of antibiotic should take into account the patient's symptoms, test results, and local resistance patterns.
- In patients with a moderate or unclear probability of UTI, urine culture should be performed to guide treatment 2.
Hematuria Evaluation
- The evaluation of hematuria should include cystoscopy and upper urinary tract imaging, especially in the absence of potential benign causes 3.
- The presence of gross hematuria may require prompt evaluation, including flexible cystoscopy, to rule out malignancy or other serious conditions 4.
- However, flexible cystoscopy may not always lead to a diagnosis or treatment, and consideration should be given to performing an upfront cystoscopy under anesthesia in some cases 4.